Admin checklist for an upcoming procedure
There is a lot to think about before having a procedure done.
The following information describes the process with your Scheme prior to a procedure being done.
Authorisation
You need authorisation for certain procedures, treatments and hospitalisation.
Anglo Medical Scheme applies two types of Reference Pricing simultaneously and will only reimburse a product at the lower of the two prices applicable to your plan option. If your doctor prescribes a product that is above any of the relevant reference prices, you will need to pay the difference in price at the point of dispensing.
To get authorisation, please phone the Call Centre as soon as you know about the procedure. Without authorisation the Scheme will not fund the services (only emergencies can be authorised 48 hours after the event). Please supply the following information:
- Membership number
- Date of admission
- Name of the patient
- Name of the hospital (or practice) and the practice number
- Type of procedure or operation, the diagnosis CPT code and the ICD-10 codes (obtainable from the doctor)
- The name of your doctor or service provider and the practice number
For more information about the authorisation process, please refer to your Benefit Guide or contact the Call Centre.
Subscribe to receive SMS services. We can then SMS your authorisation number when it’s issued, and a reminder a day before your procedure.
Pre-assessment of the costs
Let us help you understand the financial impact of your procedure with a pre-assessment of the costs.
This will give you a good estimate of what the Scheme will fund and how much you would have to pay out of your own pocket.
What to do in the case of high co-payments
Some healthcare professionals charge well above the Scheme Reimbursement Rate (SRR). However, try to negotiate with your doctor, as some members have managed to get their doctors to drop their charges by 10%-60%, with some agreeing to charge at the SRR.
When can I request a pre-assessment?
The Scheme only needs a couple of days to process and send you the pre-assessment. If you, however, request the pre-assessment a few weeks ahead of the event, it gives you enough time to renegotiate with your health care professional, or to find an alternative provider.
What information do I need for the pre-assessment?
- Before we can work on the pre-assessment, we first have to create an authorisation – we can initially work with a provisional date – just to make sure you qualify for the procedure.
- Ask your doctor for a breakdown of the cost per code, for the expected anaesthetic time and who the attending anaesthetist will be. Your doctor might charge at the SRR, but the anaesthetist may not. If prostheses are included in the procedure, please make sure that you also submit the Nappi (product) code. The pre-assessment will reflect the individual cost of what your provider charges against what the Scheme will reimburse.
- Complete and submit the Pre-Assessment form (available from the Call Centre or on www.angloms.co.za > Info Centre > Downloads > Applications).
The pre-assessment is only an estimate as the anaesthetic time, supplies needed or the procedure itself might change during the event.
What does GAP cover on the Managed Care Plan mean?
GAP cover does not mean that all costs are covered. GAP pays up to a maximum of 230% of the Scheme Reimbursement Rate for specialist services in hospital, excluding pathology, radiology and auxiliary services (230% = 100% SRR + additional 130% of SRR).